Greek researchers compared the healing results of Platelet-rich Plasma injections (PRP) to autologous blood injections in 28 patients with lateral epicondylitis (tennis elbow). These results were recently reported in Prague at the SICTO XXV Triennial World Conference 2011. Athanassios Papanikolaou, MD, explained that the study’s aim was to discover whether PRP had a distinct advantage over a less expensive injection of autologous blood.

The research conducted in Athens at Hellenic Red Cross Hospital placed patients into an autologous blood injection group (control) or a PRP group (study), with 14 patients in each. Each patient received a single 3-ml injection. PRP was prepared using the Biomet GPS III system with “sufficient” concentration levels.

Both groups saw continual improvement in pain reduction. The PRP group did slightly better in the two different measuring systems used: VAS and Liverpool scores. The greatest difference came at 6 week follow-up indicated by VAS scores, where the PRP group improved 3.8 points compared to 2.5 point improvement in the control group.

Differences at 3 weeks, 3 months and 6 months varied only slightly. With an FDA study funded by Biomet in the works, substantial information about PRP’s effectiveness and application is on the horizon. While researchers noted using Biomet’s centrifuge system, they did not report specific PRP concentration levels beyond saying that steps were taken to assure concentration levels were sufficient. Whether patients had undergone conservative treatments prior to the study and the degree of their injuries (mild, chronic, severe, etc.), has yet to be discussed. All of these considerations are crucial for researchers to include in coming studies.

A recent New York Times article questioned various treatments injured athletes may undergo to become healthy. According to the article, treatment options include steroid injections, taping, Platelet-rich Plasma (PRP) and surgery. The article questioned these methods due to their widespread use and lack of positive outcomes in clinical studies. The article made the case that PRP use is currently outpacing research-backed evidence, which is dangerous medical practice. This contention is very legitimate and needs further investigation from a clinical perspective. It is important to understand when PRP should be considered and may be beneficial. The offering of PRP by orthopedists to patients who have failed conventional treatment methods and are facing surgery, is medical practice that should be supported.

“Everyone wants to get into sports medicine,” said Dr. James Andrews in the Times article. Dr. Andrews is a sports medicine orthopedist in Gulf Breeze, Fla., and president-elect of the American Orthopaedic Society for Sports Medicine. As the article cites, oftentimes the sports medicine specialty requires less training than other specialties. This works to make sports medicine a desirable specialty for doctors following an extensive education and residency program. Beyond that, because PRP requires an injection, a fairly simple medical function, doctors from a variety of specialties are attempting to capitalize on the therapy’s popularity. This sets a dangerous precedent for future regenerative therapies and since the treatment may be considered for an injury where no clinical research supports its use, contributes to negative outcomes.

Orthopaedic specialists and orthopaedic surgeons are the researchers conducting the studies on PRP and the experts who specialize in soft-tissue repair where PRP has shown clinical effectiveness. Orthopaedic specialists have the most training and experience in these areas of the body and are most qualified to decide when PRP is an option for an injured patient. PRP should not be used recklessly just because it is popular among athletes and simple to use. Like all medical therapies, it should be carefully considered only after conventional, less costly and proven therapies have been applied.

The widespread use of PRP is partially due to professional sports. “Patients see a high-profile athlete and say, ‘I want you to do it exactly the same way their doctor did it,’ ” said Dr. Edward McDevitt in the New York Times article, an orthopedist in Arnold, Md., who specializes in sports medicine. Unquestionably, this is the wrong way to go about offering new regenerative therapies. The medical community should be attempting to obtain proper treatment applications before offering regenerative therapies such as PRP. Most often, a professional athlete uses a variety of conventional and experimental treatments simultaneously in hopes of returning to their job faster. Without treatment specifics, offering PRP because a certain professional athlete used it is irresponsible medical practice.

However, just like the professional athlete who requires an expedited return to their job, active people and workers need the same quick turnaround. Livelihoods are at stake. Most people cannot afford to take months off to recover from surgery. Therefore, to offer PRP as a last resort to surgery when conventional treatments have failed is responsible use. In these instances, orthopedists should offer PRP for injuries and conditions that have had encouraging clinical results. Cautious patients and orthopedists who recognize the importance of responsible practice should be commended. Not only does the responsible offering of PRP in specific cases “do no harm,” it may improve lives.

Dr. Christos Thanasas of Henry Dunant Hospital in Athens, Greece, published a study in The American Journal of Sports Medicine studying the effects of Platelet-rich Plasma (PRP) in lateral epicondylitis (tennis elbow). PRP involves removing a small amount a patient’s blood, concentrating healing components called platelets and re-injecting the platelets into a soft-tissue injury.

“There is now a solution for patients suffering from unrelenting ‘tennis elbow,'” said Dr. Thanasas, who led the study. Thanasas and his colleagues compared the effectiveness of single local injections of PRP under ultrasound guidance with autologous blood injections in 28 patients with tennis elbow. Visual analog pain scores at 6 weeks after the injections improved by 61.47 percent in PRP patients compared to the autologous blood group with 41.6 percent improvement from initial pain levels. Improvement continued in both groups after 3 and 6 months following injection, with no significant difference in pain scores between the treatments.

Thanasas said PRP was the best treatment for tennis elbow when conventional therapies had failed. The current option following conventional treatments is surgery. The study indicted PRP is a very acceptable and potentially successful last resort to surgery.

Thanasas concluded that further studies are needed to see how and when the PRP therapy is most effective, adding that he and his colleagues are about to start trials of PRP with varied concentrations of white blood cells to discover how PRP may help repair ligaments.

Recently, Dr. Pietro Randelli and collegues hypothesized that if Platelet-rich Plasma (PRP) were instilled in combination with white blood cells in patients who had just undergone rotator cuff repair, those patients’ recovery would be accelerated. The Italian doctors set out to study 53 patients who underwent arthroscopic rotator cuff surgery. They placed 26 patients in a PRP treatment group and 27 in a control group not receiving PRP. The results at 6, 12 and 24 months were homogeneous, barely differing. However, the treatment group experienced less pain and greater external rotation in the first 30 days following surgery. The study concluded, “The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.” The study was published in the June issue of Journal of Shoulder and Elbow Surgery.

An earlier study of Platelet-rich Plasma applied through a fibrin matrix, suggested PRP may be ineffective in expediting the healing of rotator cuffs following surgery but added, “this data should be viewed as preliminary, and further study is required.” The study’s results were reported after 6 and 12 week follow-up examinations and platelet concentration and PRP preparation methods were not reported. Dr. Randelli’s findings show that when white blood cells are added to PRP, the initial effects can be positive for patients recovering from surgery. Doctors and researchers should continue searching for PRP preparations that may aid long term healing.

A study published in February, 2010 by Dr. Taco Gosens from the Netherlands, revealed Platelet-Rich Plasma (PRP) injections were more effective than cortisone injections for chronic tennis elbow at 1 year follow-up. The controlled trial studied 100 patients with chronic lateral epicondylitis (tennis elbow). Recently, Dr. Gosens revealed the study’s conclusion at 2 year follow-up in The American Journal of Sports Medicine. In his findings, Dr. Gosens discovered pain was reduced significantly in the PRP group 2 years following the initial treatment and no complications arose. The pain level of patients in the cortisone group however, had returned to initial levels prior to the cortisone injection. This is a significant revelation as it indicates PRP may be significantly more successful in long-term pain reduction and function improvement in elbows ailed by ellateral epicondylitis.

Currently, PRP remains a therapy for patients who have failed other non-surgical treatments. As cortisone injections are temporary pain relievers and can cause tissue damage, they have also been a final resort when other non-surgical therapies fail.

Based on this study, PRP could eventually be used as a substitute for cortisone injections. PRP is shown to be more effective and has the advantage of using patients’ own natural components to heal soft-tissue tears. Cortisone as an outside agent introduced to the body, is designed to temporarily relieve pain, but can be further damaging to an injury. As evidence supporting PRP effectiveness continues to be published and insurance companies come to understand PRP’s value, the substitution may be possible.

The LA Times reported Friday, July 1, that Kobe Bryant underwent a derivation of Platelet-rich Plasma therapy (PRP) for an injured right knee in Germany. Bryant has dealt with an arthritic right knee joint in recent seasons and has undergone three other knee procedures since 2003. PRP has been indicated in multiple clinical studies to have healing potential in arthritic conditions of the knee (see PRP Knee category). During this procedure, a small portion of Bryant’s blood is removed and naturally occurring healing components called platelets, are concentrated and re-injected into Bryant’s ailing knee. The minimally invasive nature of the procedure should have Bryant practicing with less pain within weeks. In some cases, PRP is used by orthopaedic surgeons as a last resort to invasive surgery. After 15 seasons in the NBA, the 33 year old superstar is certainly hoping to avoid the rigors of another surgery.

Bartolo Colon is a 37-year-old pitcher for the New York Yankees. Last year, Colon injured ligaments in his throwing elbow and shoulder. The ramifications of such an injury for pitchers in the later years of their careers are potentially devastating. For this reason, Colon’s doctor, Joseph Purita, M.D., offered Colon an injection of stem cells harvested from Colon’s bone marrow and fat cells. Purita wanted to learn whether stem cells could help repair an aging pitcher’s ligament injury and help rejuvenate his career.

Colon’s referring Doctor, Dr. Leonel Liriano said to the Wall Street Journal this week, “When you have a guy like Bartolo Colon who was really really good, was out of baseball, but then has a comeback like he did, you have to at least wonder if this really works.” Daniel Barbarisi wrote in the same article in the WSJ, ‘Now that Colon is proving to be a success story—heading into Friday’s start against Boston, Colon was 4-2 with a 3.86 ERA—Purita says he’s seeing the possibilities everywhere and expects that other pitchers in their mid- to late-30s with nagging arm problems will sign up for the procedure, too.’

While this particular treatment has grabbed recent headlines, it isn’t exactly a novel idea. Grabbing healing cells from one area of the body and injecting them into an injury is exactly what is involved in Platelet-rich Plasma (PRP) therapy. With PRP, healing components of the blood called growth factors, are concentrated from a standard blood draw and re-injected into an injury where those factors typically have difficulty reaching. These injections may catalyze patients’ ability to heal themselves. PRP has been utilized by professional athletes, weekend warriors and injured workers needing an expedited recovery. PRP has been at the forefront of regenerative medicine. While injecting stem cells from patients’ own bodies into degenerated areas may be the next evolution in the treatment paradigm, stem cell possibilities are very much in their infancy. Extensive stem cell studies are already underway and will continue into the future.

Controversial commentary usually follows discussion of stem cell use. Because of the rampant use of HGH (Human Growth Hormone) in Major League Baseball, when baseball players are treated with injections, eyebrows are similarly raised. Thus, when stem cells and baseball players are discussed in the same sentence, critical speculation results. In an article on the NBC Sports website, writer Craig Calcaterra responded to this criticism of this particular treatment of Colon and PRP appropriately: ‘In both cases, however, the therapy itself is noncontroversial. The source of the controversy was the doctor at the center of the particular case: Anthony Galea in PRP and Joseph R. Purita in the case of Colon’s stem cell thing. Galea remains in legal trouble over his alleged use, purchase and transport of HGH; Purita because he admitted that in his non-athlete patients he uses HGH in the stem cell therapy.’

What Colon’s case represents is a single case study that may lead other aging athletes to sign up for an injection of their own cells. In the meantime, PRP remains a more developed treatment for treating soft-tissue injuries non-surgically.